0:04

As you guys see, like I always tell you,

0:06

the first thing you have to do is

0:07

to adjust everything that we're doing.

0:09

The colors. The colors.

0:11

You like to look at the transparency, everything.

0:14

So you have to put your study in the lead,

0:17

like the hanging bar hole where you,

0:21

how you wanna look at it, and then you start reading, right?

0:25

So starting with top, this is another

0:27

prostate cancer patient, but this time the disease is

0:32

predominantly bone osseous disease, not, um,

0:37

not the disease or soft tissue disease.

0:39

As you see here, all these are, see,

0:42

it's bone disease, right?

0:45

And looking through the axi images,

0:51

um, the molecular imaging is more sensitive, right?

0:56

And you can see that the extent

0:58

of the PSMA activity is definitely more than

1:03

what you see in the right.

1:11

Some of the lesions are mixed sclerotic lytic, right?

1:16

And

1:22

here, look at this, for example, in, let me put it in TAL,

1:26

because actually I like to see the spine

1:28

and the sternum in the tal.

1:30

Look at this to here in the

1:37

tic, mostly look

1:40

here, use activity.

1:43

You see a lesion and I have, lemme pull the sagittal.

1:47

I have a good sagittal constructive damage.

1:50

She can put it to see a good sagittal here.

1:55

Zoom. Now look,

2:01

definitely metastatic disease.

2:04

Do you see anything changes in the ct? No. Right?

2:09

This is, yeah, there is changes here,

2:11

but there's no changes here.

2:13

The upper body, there is changes here,

2:18

but, and I mean, I'm, I'm just looking with you guys.

2:22

I'm not, I wasn't really planning exactly

2:26

what am I gonna say on this, but,

2:29

but we know that, I mean, it's something that we always see

2:32

with molecular imaging that we are more sensitive,

2:38

we see more disease.

2:40

And then the other end of the spectrum,

2:43

when the patient is responding to treatment,

2:47

we prove treatment response.

2:49

Like sclerotic lesions remains sclerotic on ct while the

2:54

molecular imaging shows the resolution of, um,

2:59

active disease, right?

3:01

So we always are more sensitive in showing the disease

3:03

extent and in showing the treatment response,

3:06

uh, level, right?

3:08

Same here. Look

3:09

here, you see that.

3:15

Now see on here the same thing. So I made the point.

3:22

Molecular imaging functional image is gonna show you the

3:27

disease extent, the real disease extent,

3:29

not anatomic image, right?

3:32

It's beautiful. Now I like to look at the

3:37

coronal image for the pelvis.

3:41

I'm gonna show you everything.

3:42

The old, because it's,

3:43

it's predominantly bone in this patient.

3:47

So I'll take my time showing you the

3:50

bone here.

3:55

So pelvic pelvic bones, um,

3:58

coronal image is the best to look at the pelvic bone.

4:02

The same thing. Look here, look at this and look at this.

4:07

Definitely the functional image,

4:08

what's showing you the disease.

4:10

Then atomic image is definitely underestimating the disease.

4:13

Disease. Nobody can argue with me with this, right?

4:23

So, um,

4:28

think I made the point, let me go back to the axial image

4:34

and um,

4:40

think through the study.

4:41

There is nothing else. Everything is negative.

4:44

It's just, it was predominantly

4:46

really, I mean, here look at this.

4:49

I think it saw assist in that, yeah. Is happening.

4:57

Do you still hear me Ney?

5:02

Yes, I can hear you good.

5:04

Um, because it should give me like an error message.

5:07

So here I picked it up here. It's totally photogenic, right?

5:11

So it's, this is around contrast.

5:13

I see a hypo attenuating lesion on the liver.

5:16

I look at my functional image

5:18

and this, this holds up in dotatate and FDG

5:21

and PSMA, whatever,

5:23

when it's totally photogenic like this, like a hole.

5:26

This is cyst. No doubt.

5:29

When the activity is similar to barma, then it's not cyst.

5:33

It might be a hemangioma.

5:35

Then I start saying this, well, there's a, you know,

5:38

hypo annuating lesion where the activity similar

5:40

to the brain might be cyst or a hemangioma,

5:43

but when it's like this, this is definitely assessed, right?

5:49

So there's like liver cyst, but nothing else.

5:52

No soft tissue lesions. Um, no prostatectomy,

5:57

Bed re currently p smma avid of course we always say PSMA,

6:01

avid recurrent lesion.

6:03

P ssm a avid metastatic adenopathy, P smma, avid.

6:06

You have to emphasize that. Why? 'cause this is an UNC city.

6:09

I'm not gonna say it's a low resolution,

6:11

it's not a low resolution.

6:13

It's, it's an okay resolution.

6:15

I'm not gonna say non-diagnostic for localization.

6:18

I don't believe in this. We read the city,

6:20

we do re in our situation, we do read the non-contrast city.

6:23

It's not, the idea is a non-contrast city, right?

6:28

Um, I can't reconstruct this in thinner,

6:32

in in a thinner slices if I want.

6:34

It's just that we do a whole body

6:36

and we already end up with thousands of images.

6:39

If I reconstruct on a a one millimeter, then it's gonna,

6:42

I'm gonna overwhelm our packs.

6:44

This is why we end up

6:45

with reconstructing with three millimeter.

6:47

Maybe just because I can't do,

6:50

and sometimes five millimeter just

6:52

because it's, we already end up with 3000,

6:54

4,000 images, right?

6:57

I cannot overwhelm my packs with more. We do a lot.

7:00

We acquire, because we cover the

7:02

whole body in all our cases.

7:03

Like this is the least covers we do like torso to mid thigh.

7:07

Some cases we do whole body.

7:09

Some cases we do torso and zoom or whole body and zoom neck.

7:14

So I just can't overwhelm it with thinner slices.

7:17

But we have the capability

7:18

because we actually acquire spiral images, right?

7:20

So I have the capability

7:21

of reconstructing thinner slices than this.

7:25

Um, but it's a non-city. I don't get all the kernels.

7:29

Like I don't do all, all the things that I wanna do for, um,

7:34

like to do a, a fully diagnostic C yes, I don't,

7:40

but it doesn't mean that this is, I'm not acquiring the

7:44

low re what they call a law resolution c just done

7:47

for a simulation correction.

7:48

This is not that There are low resolution CT

7:52

that can be acquired just for affirmation correction.

7:54

And this is not what it is, right?

7:57

And there's a lot of the agno, there's a lot of, um,

7:59

diagnostic information that I can get out of the ct

8:01

and we do, we read the CT as well.

8:04

But because of the lack of contrast, also

8:09

there are information that I'm not getting.

8:11

I cannot draw from the ct.

8:13

This is why we have to always emphasize that

8:16

what we are excluding is

8:18

that there's no pss m avid recurrent, there's no PSM avid

8:22

or in the case of fgg, there's no hypermetabolic, there's no

8:26

SOTA avid or dotatate avid.

8:29

'cause this is our power, the functional, the the metabolic,

8:32

the molecular aspect of the disease.

8:37

And this is why this patient's coming to us,

8:39

patient will get a conscious,

8:40

like a diagnostic conscious C, right?

8:44

And not in our suite in a different treat.

8:48

The he's come this patient coming to us

8:50

for the functional image, for the molecular image.

8:53

So this is, this is why the patient is coming to us, right?

8:57

Um, and this is it for this case.

8:59

This is a, a bone predominant,

9:01

predominantly bone osseous lesions

9:05

different than bone scan.

9:07

Bone scan is not specific sensitive, not specific

9:10

and doesn't mean it's not important.

9:11

It's important. But an experienced read reader,

9:15

you can differentiate between degenerative changes,

9:17

the benign lesion and the metastatic lesion.

9:19

Definitely you can, right? Yes.

9:22

It's not, it's, it's very sensitive.

9:24

Not specifically when, when you,

9:26

when you're looking at the bone scan

9:27

and saying everything hot is metastatic disease

9:31

and none of us do that, we can differentiate it, right?

9:36

But you have to understand also the bone scan is

9:39

detecting MDB is detecting

9:41

what phosphonate is detecting osteoblastic activity.

9:46

The job of bone scan is not to detect the static disease is

9:49

to detect any area with bone building,

9:53

bone remodeling, right?

9:55

So when you put this in mind, you'll understand

9:58

that bone scan job is not

9:59

to detect metastatic disease, right?

10:02

But PSM E is different.

10:04

PSM E is detecting prostate specific membrane antigen.

10:08

So you are specific, you know what you're looking for.

10:12

So when you put this in context, you know, you,

10:16

you can diagnose better, you know your tool

10:18

and you know your limitation.